A nurse is assessing the level of consciousness of a patient who has sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy but the nurse is able to wake the patient by gently shaking and calling the patient by name. What level of consciousness would the nurse document?

A. Use standard precautions in caring for all clients:

Standard precautions involve applying infection prevention practices to all clients, regardless of their known or suspected infectious status. This includes hand hygiene, use of personal protective equipment (PPE), and safe injection practices. Standard precautions are designed to prevent the transmission of microorganisms and break the chain of infection.

B. Place all post-surgical clients in contact isolation:

Contact isolation is typically used for clients with known or suspected infections that can be spread through direct or indirect contact. Placing all post-surgical clients in contact isolation may not be necessary unless there is evidence of a specific infectious condition.

C. Order IV antibiotics for all clients with sacral pressure wounds:

Ordering antibiotics is a specific treatment for bacterial infections but does not address the broader approach of breaking the chain of infection for all clients.

D. Limit visitations to 2 people a day for each client:

While limiting visitations can reduce the risk of introducing infections, it does not address the nurse's direct care practices and adherence to infection prevention measures.

A. Do not let the patient know you are counting their respirations:

This is not directly related to obtaining vital signs and is not a critical factor for a patient with a low platelet count.

B. Let the patient rest for 5 minutes before you measure their blood pressure:

Allowing the patient to rest for a few minutes before measuring blood pressure is a good practice but may not be as critical as other considerations in a patient with a low platelet count.

C. Do not measure the patient’s temperature rectally:

Patients with low platelet counts are at an increased risk of bleeding. Rectal temperatures can be invasive and carry a risk of mucosal injury, making them less advisable in patients with bleeding risks.

D. Count the patient’s radial pulse for 30 seconds and multiply it by 2:

Counting the radial pulse is a suitable method for assessing heart rate in a patient at risk for bleeding. However, rectal temperature measurement should be avoided due to the risk of mucosal injury.